From the Guidelines
The management of Central Retinal Vein Occlusion (CRVO) or Branch Retinal Vein Occlusion (BRVO) should prioritize intravitreal anti-VEGF injections, such as ranibizumab, as first-line therapy, as demonstrated by the BRAVO trial 1.
Key Considerations
- The BRAVO trial showed that monthly intravitreal ranibizumab injections resulted in a significant gain of 16 to 18 letters in visual acuity compared to sham injections at 6 months 1.
- The HORIZON trial, an extension of the BRAVO trial, demonstrated that the benefits of ranibizumab were generally maintained at 12 months, with approximately half of the eyes achieving resolution of edema and 80% having visual acuity of better than or equal to 20/40 1.
- Other anti-VEGF agents, such as bevacizumab and aflibercept, have also shown efficacy in treating macular edema associated with BRVO, although ranibizumab is the most extensively studied 1.
- Intravitreal corticosteroids, such as dexamethasone implant, may be considered as alternative or adjunctive therapy, particularly in pseudophakic patients or those with insufficient response to anti-VEGF therapy 1.
- Laser photocoagulation is considered for persistent macular edema or for treating areas of retinal ischemia in branch retinal vein occlusion, and panretinal photocoagulation may be necessary for patients with neovascularization 1.
Treatment Approach
- Initial treatment includes addressing risk factors such as hypertension, diabetes, and hyperlipidemia.
- Intravitreal anti-VEGF injections are administered monthly until the edema resolves, then as needed.
- Regular follow-up with visual acuity testing and OCT imaging is essential to monitor treatment response and detect complications early.
- Patients should be educated about the importance of controlling systemic risk factors and recognizing symptoms of worsening vision that require immediate attention.
Safety and Efficacy
- The use of anti-VEGF agents has been shown to be safe and effective in treating macular edema associated with BRVO, with minimal side effects 1.
- Severe adverse effects of intravitreal injections are uncommon, but may include infectious endophthalmitis, cataract formation, retinal detachment, and elevated IOP 1.
From the FDA Drug Label
The safety and efficacy of ranibizumab were assessed in two randomized, double-masked, 1-year studies in patients with macular edema following RVO. Patient age ranged from 20 to 91 years, with a mean age of 67 years. A total of 789 patients (ranibizumab 0.3 mg, 266 patients; ranibizumab 0. 5 mg, 261 patients; sham, 262 patients) were enrolled, with 739 (94%) patients completing through Month 6. All patients completing Month 6 were eligible to receive ranibizumaz 0.5 mg intravitally guided by pre-specified re-treatment criteria until the end of the studies at Month 12. In Study RVO-1, patients with macular edema following branch or hemi-RVO, received monthly ranibizumab 0.3 mg or 0. 5 mg intravitally injections or monthly sham injections for 6 months. In Study RVO-2, patients with macular edema following central RVO received monthly ranibizumab 0.3 mg or 0.5 mg intravitally injections or monthly sham injections for 6 months.
The management of Central Retinal Vein Occlusion (CRVO) or Branch Retinal Vein Occlusion (BRVO) includes the use of ranibizum 0.5 mg intravitally injections, with possible re-treatment guided by pre-specified criteria. Key points to consider in the management of CRVO or BRVO include:
- Intravitally injections: ranibizumab 0.5 mg given monthly for 6 month
- Re-treatment criteria: guided by pre-specified criteria after the first 6 month of treatment
- Visual acuity outcomes: significant improvement in visual acuity observed at Month 6 in patients treated with ranibizumab 0.5 mg compared to sham 2
From the Research
Management of Central Retinal Vein Occlusion (CRVO) or Branch Retinal Vein Occlusion (BRVO)
The management of CRVO or BRVO involves the use of intravitreal agents based on anti-vascular endothelial growth factor (VEGF) or anti-inflammatory strategies.
- The primary treatment against macular edema with retinal vein occlusion (RVO) has changed from observation in central RVO (CRVO) and laser photocoagulation in branch RVO (BRVO) to administration of intravitreal agents based on anti-VEGF or anti-inflammatory strategies 3.
- Anti-VEGF treatment such as ranibizumab, bevacizumab, or aflibercept improved vision by 13.9-16.2 letters (best-corrected visual acuity) after 12 months versus baseline in patients with macular edema secondary to CRVO 3.
- Anti-VEGF agents such as ranibizumab or bevacizumab improved visual acuity by 15.5-18.3 letters in patients with macular edema secondary to BRVO after 12 months 3.
Treatment Strategies
- Intravitreal injection treatment for the management of macular edema as an expression of increased capillary permeability and leakage constitute the mainstay of treatment in retinal vein occlusion 4.
- A functional treatment success can be maintained over the long term by both pro re nata (PRN) or treat and extend (T&E) regimens 4.
- In patients with recalcitrant macular edema, switching to another intravitreal agent may be considered during the course of treatment, although a true therapeutic benefit with respect to the development of visual acuity has not yet been proven 4.
Importance of Early Treatment
- The efficacy of therapy depends primarily on the precociousness of the therapy after the diagnosis of central/ hemicentral retinal vein occlusion 5.
- Any delay in the treatment will adversely influence the restoration of visual functions, which are difficult to correct even with subsequent treatment 5.
Available Treatment Options
- Currently, 2 anti-VEGF agents (ranibizumab and aflibercept) have been FDA and EMA approved for the treatment of RVO, while another VEGF inhibitor (bevacizumab) is often used "off-label" in clinical practice 6.
- Many treatment regimens have been suggested in the clinical trials with these drugs, as monthly injections or injections when needed, however, the ideal regimen has not been defined yet 6.